Bacterial Endophthalmitis Clinical Presentation

Updated: Sep 20, 2018
  • Author: Robert H Graham, MD; Chief Editor: Hampton Roy, Sr, MD  more...
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The clinical presentation is dependent on the route of entry, the infecting organism, and the duration of the disease. In general, patients complain of a decrease in vision, often with a red eye. Most patients also may complain of a deep ocular pain. Classification is based on routes of entry. [1]

Exogenous source

Acute postoperative (< 6 wk postoperative), as follows: [2, 3]

  • Infection usually occurs 2-10 days after surgery.

  • Patients present with visual loss greater than expected in the usual postoperative course.

  • Ocular pain is seen in 75% of patients.

  • The use of postoperative antibiotic and anti-inflammatory drugs may blunt the severity of the disease and possibly delay medical attention.

Delayed onset or chronic pseudophakic postoperative (>6 wk postoperative), as follows: [2]

  • Patients typically present with mild-to-moderate inflammatory red eye, reduced vision, and photophobia.

  • Chronic indolent course is present.

  • Patients may be diagnosed with idiopathic uveitis and treated with topical steroids with temporary improvement.

  • Fungal species must be ruled out.

  • Filtering bleb associated: Clinical features are similar to acute postoperative infection with purulent bleb involvement. [24]

  • Posttraumatic: History of trauma is present, and infection usually progresses rapidly. [4]

Endogenous source

No recent history of ocular surgery is present.

Confusion with delayed onset or chronic postoperative is possible if suspicion for endogenous route is not ruled out.

The symptoms are rarely bilateral.



General findings include the following:

  • Visual acuity decreased below the level expected

  • Lid edema

  • Conjunctival hyperemia

  • Corneal edema

  • Anterior chamber cells and flare

  • Keratic precipitates

  • Hypopyon [5]

  • Fibrin membrane formation

  • Vitritis

  • Loss of red reflex

  • Retinal periphlebitis if view of fundus possible [6]

Specific findings include the following:

  • Delayed onset or chronic: Occasionally, a white plaque is visible within the equator of the remaining lens capsule.

  • Filtering bleb associated: A purulent bleb is seen occasionally with areas of necrosis in the sclera from the use of antimetabolites.

  • Posttraumatic: Evidence of penetrating trauma is seen with the possibility of an intraocular foreign body. [7, 8]

  • Endogenous: Patient may appear systemically ill.



Causes are related to classification of exogenous and endogenous, as follows: [25]

  • Exogenous (see below)
    • Ocular surgical procedure - Increased risk when complications arise
    • Trauma
    • Ocular surface infection (eg, corneal ulcer) - Zapp et al conclude that enucleation should be considered against the risk of systemic and local spread of the infection [26]
    • Filtering bleb associated - Use of antimetabolites or contaminated contact lenses
    • Intravitreal injection - Injections of intravitreal agents to treat exudative macular degeneration, as well as macular edema due to diabetes or retinal vaso-occlusive disease, have an endophthalmitis rate of 0.019%-0.09%, according to Lau et al [27]
  • Endogenous (see below)
    • Septicemia
    • Patients who are debilitated
    • Indwelling catheters
    • Intravenous drug use

Bacteria involved include the following [28] :

  • Acute pseudophakic postoperative - Coagulase-negative staphylococci, Staphylococcus aureus, and Streptococcus, Enterococcus, and gram-negative species [29, 8, 30, 31, 4]
  • Delayed onset or chronic pseudophakic postoperative - Propionibacterium acnes, and coagulase-negative and Corynebacterium species [29, 8, 30, 31, 4, 32]
  • Filtering bleb associated [33] - Streptococcus and Staphylococcus species and Haemophilus influenzae
  • Posttraumatic -  Bacillus [34] and Staphylococcus species [35]
  • Endogenous -  S aureus, Escherichia coli, and Streptococcus species


See the list below:

  • Retinal necrosis

  • Retinal detachment (see below)

    • Retinal necrosis

    • Vitreous tap

    • Vitrectomy

  • Increased intraocular pressure

  • Retinal vascular occlusion

  • Optic neuropathy

  • Panophthalmitis

  • Hypotony (see below)

    • Ciliary body shutdown

    • Wound leakage

    • Retinal detachment

    • Cyclodialysis cleft

    • Medication